Calling overseas doctors an 'interim' workforce is dangerous

Since its inception in 1948, the NHS has benefited from the contributions that overseas doctors, nurses, midwives and other allied health professionals have made to the NHS. Without the skills and commitment of these staff, the NHS would be in dire straits.

NHS leaders from the Secretary of State for Health downwards have publicly welcomed and praised this invaluable contribution to the health and wellbeing of the UK population.

The need now is for better integration not further fragmentation of the workforce

The proposal that a new NHS workforce strategy will seek to turn overseas doctors into an 'interim' workforce creates a grave risk for the NHS and may make the supply of doctors worse in the short and medium term. This risk is particularly the case for shortage specialties such as psychiatry, obstetrics and gynaecology, paediatrics and emergency medicine, which remain heavily reliant on international medical graduates (IMGs) despite a nationwide effort at improving recruitment rates. And not forgetting the current recruitment crisis in general practice.

Coming on top of the uncertainty EU medical staff are facing post Brexit, this proposal can only have the effect of severely demoralising doctors already working for the NHS and risk deterring others whom the UK may wish to recruit.

The GMC State of Medical Education and Practice in the UK report states that in 2015 77,714 doctors (33.1% of doctors working in the NHS) completed their primary medical qualification outside of the UK. Of the 59,068 GPs, 12,864 are overseas doctors accounting for 21.8% of GPs. Of the 72,024 specialists in the country, 28,190 are overseas doctors, accounting for 39.2% of specialists. In 2014, there were 8574 psychiatrists on the specialist register and of these 3638, 42% of all psychiatrists, were not originally UK trained.

It is evident that the NHS makes substantial savings on training costs from the presence of these overseas doctors. Even assuming a conservative assumption of the training cost of £250,000 per doctor, this group of doctors have saved the NHS and the Treasury a whopping £19 bn. Only a tiny proportion of this saving is used to support the integration of these doctors in the NHS. In the absence of such support and additionally due to medico-political or immigration regulation, many have fallen off the conventional career path, unable to become consultants and end up working as staff grade, associate specialists and specialty doctors, a group who have often complained of being used and abused as workhorses by the NHS. Differential pass rates in exams between IMGs and UK-qualified candidates have furthered this perception.

Despite this, they constitute an indispensable part of the frontline NHS workers. In addition to the financial gains, we must not forget the vast clinical and administrative experience this subset of workforce brings into the NHS as the achievements of many of these alleged ‘interim’ workforce demonstrate.

On 4 October 2016, the Prime Minister told BBC Breakfast, before an announcement at the Conservative Party conference by Jeremy Hunt, that whilst overseas NHS staff were welcome to stay for now, 'there will be staff here from overseas in that interim period – until the further number of UK doctors are able to be trained and come on board in terms of being able to work in our hospitals.' Although Ms May backtracked from this comment, she did so only to insofar as saying that it was upto local hospitals to make that decision. There was a failure by her to recognise that recruitment of medical trainees is a job for Health Education England and not local hospitals and of course this would have been a splendid opportunity for her to recognise the contribution of overseas doctors in the NHS.

Doctors in the NHS are working harder than ever. Teams of doctors from all corners of the United Kingdom work alongside colleagues from many parts of the world. Given the current increase in racism experienced post Brexit, and compounded by proposals to force employers to publicly announce how many 'foreign' staff they employ, much overseas staff are becoming increasingly apprehensive.

While it is vital to have a long-term NHS workforce strategy, it is dangerous to make even the subtlest hint that may suggest the move to a Government that does not recognise the value of migrants. It is dangerous to propose a future self-reliant workforce strategy based on poor financial modelling and assumptions. Whilst recruitment and retention worsens, the NHS will continue to rely on the expertise of overseas doctors who have time and time again, helped to hold the NHS together.

Understandably, there have been concerns about 'brain drain' from the developing world. The Medical Training Initiative (MTI) scheme was initially set up as a fixed two-year term training scheme with aims to provide advanced medical training and service experience for overseas doctors to improve the management and treatment of patients around the world. However, this scheme does not now appear to be funded or supported to deliver these aims and instead some MTI trainees have felt exploited as cheap labour.

Several Colleges supported by the GMC, BMA and diaspora doctors’ associations have been working hard over the past few years to address the notion that overseas doctors are used as a cheap fodder to cover rota gaps across the UK. The message of classifying international medical graduates as an 'interim' workforce runs the risk of demoralising, dehumanising and objectifying these doctors and flies in the face of these endeavours and the very values of a fair society. Medical leaders and organisations would do well to pool their resources to address the issue, as this is going to be a recurring theme for the coming years.

Political leaders would do well to remember this before they add fuel to the fire with irresponsible comments that aggravate the 'them' vs 'us' paranoia and worsen the divide at a time when attacks on overseas workers and their families have sharply increased. Many NHS leaders have shared our concerns publicly but with no obvious change in policy focus or rhetoric from politicians. It is worth remembering that a significant number of originally 'overseas doctors' are now UK citizens, having dedicated most of their professional life to the UK health service. While rifts and divisions continue to emerge, it may be a worthwhile exercise for the Government to reflect on what the definition of a foreign trained doctor even is.

The NHS has spent millions to improve engagement with clinicians because evidence shows that a well-engaged workforce is a key to providing a safe and efficient service for patients. The current xenophobic stance is not only antithetical to the UK culture of acceptance and tolerance but is likely to disengage in one fell swoop, a large part of the workforce with the attendant risk of worsening the quality of care provided to patients.

We call upon politicians, and ministers in particular, to reflect on their statements and withdraw the suggestion that overseas doctors are required to be here only for an 'interim' period. Until more robust financial and workforce modelling is available, this suggestion will worsen not improve the current workforce pressure, particularly in shortage specialties. We also call upon the Government to ensure that adequate funding is provided to engage and support all current employees of the NHS.

The need now is for better integration not further fragmentation of the workforce.

Unfortunately I fear that these comments are part of the Tories' masterplan to bring down the NHS completely and facilitate privatisation. Getting IMGs, a very significant proportion of the medical workforce, to pack up and leave and deter others from arriving might well do the job for them. Surely no government whose intention it is to preserve the NHS would make such damaging statements at the most inappropriate of times. Clearly there is a pattern emerging: pick the most unpopular plan and the worst possible moment for launch and collapse is assured. Rational argument even if as eloquent as this letter will fall on deaf ears.

'Things are clearly not what they seem' as we always say. It is difficult to fathom how downwards this situation of NHS had gone without re-visiting what the 'still new' PM said in her party conference several weeks ago :'''.......Like the NHS – one of the finest health care systems anywhere in the world, and a vital national institution. An institution that reflects our values, our belief in fairness, and in which we all take enormous pride. And I mean all. Because there is complete cross-party support for the NHS. For its status as a provider of free-at-the-point-of-use health care. For the thousands of doctors and nurses that work around the clock to care for their patients. We all have a story about the nurse who cared for a loved one, or a surgeon who saved the life of a friend. So let us take this opportunity to say to those doctors and nurses – thank you. The NHS should unite us. But year after year, election after election, Labour try to use it to divide us. At every election since it was established, Labour have said the Tories would cut the NHS - and every time we have spent more on it. Every election, they say we want to privatise the NHS - and every time we have protected it. In fact, the party that expanded the use of the private sector in the NHS the fastest was not this party, but the Labour Party. The only party to ever cut spending on the NHS is not this party, but the Labour Party – that’s what they did in Wales. And at the last election, it wasn’t the Labour Party that pledged to give the NHS the money it asked for to meet its five-year plan – it was this party, the Conservative Party… investing an extra £10 billion in the NHS – more than its leaders asked for… and this year more patients are being treated, and more operations are being carried out, by more doctors and more nurses than ever before. That’s a tribute to everyone who works in the NHS. But also to one man – Jeremy Hunt – who is one of the most passionate advocates for patients and for the doctors, nurses and others who work in our health service that I have ever known. So let’s have no more of Labour’s absurd belief that they have a monopoly on compassion. Let’s put an end to their sanctimonious pretence of moral superiority. Let’s make clear that they have given up the right to call themselves the party of the NHS, the party of the workers, the party of public servants. They gave up that right when they adopted the politics of division. When their extreme ideological fixations led them to simply stop listening to the country. When they abandoned the centre ground. And let us take this opportunity to show that we, the Conservative Party, truly are the party of the workers… the party of public servants… the party of the NHS.......''

While she clearly took the opportunity to steal some good points from the leftists, she wasted no time to ridicule their pitfalls with swift aloofness. The Tory would be the 'nasty party' (the term she created while her party was in political wilderness those years) no more . And her party would be the party of the NHS etc.My verdict is ,simply , she needed this speech more than anybody else because she knew the reality was to bite her back very quickly . After all , politics is about winning the public over.But politics is also about winning over your colleagues .That is exactly where her honeymoon of premiership rapidly coming to the end of its lifespan . A godfather would always love his loyal lieutenants and try to wipe the 'rats' . Trouble for Auntie right now is who are the lieutenants , who are the rats? (Superficially , one can see three rats already running around with one only wanted to be the PM in the first place).The complication comes from Brexit ,which as I said before , had caused distractions on everything. Fundamentally, one has to question the PM seriously ,deep down, which way is she swinging or is she just an opportunist setting a target of being Thatcher 2.0? Friends or foes in her cabinet?The seat of the PM has never been more uncomfortable . One thing quite evident is she in the process of going separate way with her presumed closest lieutenant, the Chancellor , who is her first-class honour university alumnus. If immigration is the core of argument for Brexit , the economy is the counterpart for staying in European single market . One cannot have it all . The official dialogues about Brexit from these two so far had been contradictory , PM on immigration zone and the Chancellor on the economy. For us , the ideology of 'interim workforce' , the four year sentence of going nowhere for medical students after graduation and the eventually self-sufficient(really hate this term!) condition using only UK grown medical staff , see its daylight under the PM's version of 'hard Brexit'. Let's be honest , it is probably right to say : No Brexit , No May as the PM. But this put the Chancellor in the most embarrassing position and deep down, he really did not want this headache of leaving EU. The value of pound had gone as expected and history told us currency depreciation is entirely disastrous and I can understand why Melvin King's immediate comment was a welcoming one. But the question is 'what 's next?'. The mentality of the government is somehow it could still 'convince' the EU for agreeing something as a happy medium as well as striking good deals with other countries, China, US etc. But the current failure of striking a trade deal between EU and Canadian government tells you about reality. The irony is probably half of those voting to leave still want to stay in the single market .The 'deadline' as the story goes , is destined on 1st April next year when the PM , as announced, will invoke article 50.As many economists suggested , the solution to this mess appeared to be a Keynesian approach : the government has to exert more fiscal power as the Bank of England had already done what it could do in quantitative easing . This entails more infrastructure investment etc. and it means more borrowing and more ruthless savings from somewhere.It is impossible to reach a surplus by 2020 which was the obsession as well as bargaining chip to be the next PM as far as the ex-Chancellor was concerned.In effect, this situation was a good slap on his face but obviously the circumstances are completely new now.However, that also has ridiculed the infamous £350 millions to be injected into NHS weekly . Instead , we have STP(sustainability and transformation plan) on our plate . All the evidences and many feedbacks from NHS executives had suggested mission impossible . The whole ideology boils down from the top pushing for less hospital beds or even hospital closures , poorly thought-through transfer of workload from secondary to primary care with questionable funding , but the most stifling part is perhaps this interim workforce and eventual self sufficiency serving the PM's agenda of pleasing the school of immigration control .Yes, the honeymoon is certainly over as soon as both the PM and Chancellor told Simon Stevens in private conversation that there was no extra money into NHS and one could only see half of the £10 billions supposed to go into NHS by 2020. I was reading a very interesting article on The Economist about why Hillary Clinton has been so unpopular even though Trump's reputation is going down the drain:http://www.economist.com/news/united-states/21709053-americas-probable-next-president-deeply-reviled-why-hating-hillary

It's conclusion was largely down sexism . I can understand the reasons why Auntie May wanting to be Auntie Thatcher 2.0 while you are sitting in a cabinet with a lot testosterone flying around and fundamentally your party is a right winged one. But who is to be mattering the most , your colleagues, hence , party OR the country ?